Tag: cardiovascular risk prediction

It is really great to post the European Society of Cardiology/European Society of Hypertension Guidelines about Arterial Hypertension. Just presented at the 28 th European Meeting of HTN and cardiovascular protection held last June in Barcelona.

Such a great honor having been there when the guideline was publicly released for first time.

After several years studying the subject of cardiovascular disease early in life and with some papers published recently about it (1-5) I can say that nowadays, as health care providers, we are facing several cardiovascular disease contributing risk factors (hypertension, obesity, smoking, unhealthy diet, etc.) which prompts a large burden on our shoulders as they keep leading to a long-lasting and quite steady worldwide prevalence of heart conditions, stroke, kidney failure, premature death and disability for the last 20 years. (6)

Even, children and adolescents are not spared from this. For instance, according to the latest European (7) and North American Guidelines about the subject (8), the prevalence of high blood pressure in children and adolescents ranges between 3 to 11 % and rises up to 40 % when obesity is in place as well.

The above mentioned is a known fact that unfortunately is ongoing with some ups and downs but continue to be a pending endeavor yet to be solved by the medical community. Thus, I do not want to dwell on it on this post.

At the moment, I am more interested on reflecting how these spotlighted main risk factors might be blindfolding us from seeing “little facts” that are having also an impact on the complex setting related with the development of cardiovascular disease and sadly are often overlooked.

In this light, there is one fact which is not as publicized as the main risk factors mentioned above which is critical my opinion. I am referring to the buccal hygiene and its links to cardiovascular disease.

To get started, it is worth mentioning that the surfaces of the human body are heavily colonized by a varied microbial ecosystem called the microbiota, in other words, this is a mixed community of microorganisms composed of bacteria, viruses, archaea, and eukaryotic microbes that coinhabit in our body . The gathering of those microbes and their genes is named the human microbiome and each person has a unique microbiome which varies along with our genetic background, age and life style (9)

As per the aim of this paper, I will point out at the oral microbiome, which is considered one of the most highly dynamic ecosystems in the human body.

According to the latest investigations, the estimated number of bacteria in the mouth is up to 100 billion and comprised nearly 700 identified bacterial species being the most prevalent Firmicutes and Proteobacteria, along with Bacteroidetes, Actinobacteria, and Fusobacteria (10)

Though, the oral microbiome is dynamic in terms of functioning, as ecosystem must be stable in its composition and structure. Any disruption in it leads to a state called dysbiosis.

Recently, multiple animal and human studies have examined the relationship between the oral microbiome disruption (dysbiosis) and blood pressure and have reported important insights explaining such links.

The most important proposed links to hypertension would be the following:

The concept of “predisease” arose in 1914 when Dr. William Rodman came up with the idea of intervening early on those patients having signs of a precancerous state. However, Rodman acknowledged that his thesis would be controversial when noted: “I am aware that the term precancerous can be objected by at least two reasons: first, not always there will be a precancerous state; second, if this state existed, it does not mean that cancer will develop”.

Nevertheless, with the goal in preventing the appearance of morbid events, predisease as category makes sense if the following three conditions are met: 1) individuals who fall into this category should be more likely to develop disease; 2) There must be a an intervention that when directed towards this individuals at risk be effective in reducing the risk of evolution to disease, and 3) the benefits of intervening on the pre-disease must exceed the risks. Currently, the state of predisease applies for various conditions: pre-diabetes, pre-hypertension, subclinical thyroid dysfunction or even individuals tested positive for human immunodeficiency virus. All these clinical situations involve an increased risk of developing the disease. Although the lapse of time for this to happen might be uncertain in most cases, lots of studies have shown that there can be several damages at molecular and cellular levels that might be impairing tissues and at the same time fueling the occurrence of the disease.

Then, I wonder, are the current and most used cut-off points in medical practice really reliable to advise a patient on whether he or she has an unhealthy condition?

In the author’s opinion, a fundamental limitation of the cut-off points is that their use on biological variables might be biased since there is not any reliable foundation to do so. However, we keep labeling individuals as healthy or sick based on them and it has been this way since a long time and probably will be until we consider the problem more comprehensibly and stop staying on shallow waters instead of going into the deep end.

I acknowledge that currently the decision-making process would be very weak without cut-off point to make decisions but we must be very cautious when giving an opinion based on them.

In addition, it is valid to say that most of the cut-off points we use in our day to day practice with patient are not autochthonous but they have been taken from guidelines, pathways, etc that have nothing to do with the population of patient we deal with.

Can you imagine what would it be like to use a cut-off points to determine if one individual living in the middle east had any health condition using cut-off points offered by health institutions based in Canada, USA or Asia? It sounds like nonsense, however we do it every day. Why? because we have never thought on it. Some time we simply use what we have been given or taught as the best evidence, but this evidence is far away from us in terms of ethnicity, genetics or socioeconomic status and these factors indeed could have been a significant statistical impact in the countries they were used when where pooled to yield certain cut-off figures, but it does not mean that can be widely used across regions and continents.

Accordingly, I think that each country’s medical society must dig deep and pull out its own cut-off points, otherwise we will continue to miss key elements when it comes to diagnosing in medicine.

In the end my dear colleagues, the autochthonous is and always will be the most consistent and reliable. To be enticed by names of medical associations with a well gained fame in terms of taking all they offered as the absolute truth can be deceptive. So, never fall into the “Band Wagon“ fallacy (if most people like them, then they must be okay)

On one next post, I will expose some examples of some steps taken on this.

This is an excerpt of a publication of mine sent to a peer review journal by me to be published.

Since the publication in 1977 of the First American Task Force for the diagnosis, evaluation and treatment of high blood pressure (BP) in children and adolescents, updated in 1987, 1996 and more comprehensibly in 2004 (as Fourth Report) has been stressed out the importance of HTN related organ damage being, in this context, LVH a paradigm. Likewise, the latest European Society of HTN guidelines for the management of HTN in children and adolescents published in 2016 has highlighted the assessment of subclinical organ damage as an intermediate stage in the continuum of vascular disease as well, targeting predominantly LVH (2) Woroniecki and colleagues’ article (1) exposed the somehow puzzling issue when it comes to defining LVH in pediatric population on the basis of the existence of diverse criteria with pros and cons. These arguments are not new and have made very difficult over years to ascertain a reliable standardization of LVH definition at the early stages of life in children and adolescents suffering from HTN. Although, the authors of the article do not mention the connection of prehypertension with LVH, this association exists (3) and can trouble even more the things to decipher a definition of LVH for prehypertensive patients since the long-established studies that have reported the different formulas to define LVH in children and adolescents have been conducted on hypertensive individuals (2)

Unquestionably, the search for a definition of LVH in the context we are commenting here is complex with multiple answer and a solution far to be beheld to date; even though, the future might unfold some results especially with the American Heart Association’s SHIP-AHOY study, intended to evaluate blood pressure thresholds, ambulatory blood pressure, and metabolic phenotype that predicts hypertensive target organ damage. In addition, it is planned an update of the Fourth Report that would help with the necessary consensus on LVH (3)

In the meantime, according to our opinion, the appraisal of HTN induced LVH must get ahead of the simple quantification of left ventricular mass by focusing on the early diastolic alterations as regional mitral Ea, Aa and the E/Ea ratio by Tissue doppler imaging that precede the onset of LVH since this hypertrophy can be observed with the use of steroid, obesity, athletes, growth hormone use, etc., therefore can be reversible (4)

Those topics are not mentioned in Woroniecki and colleagues’ article (1) and might be key to increase consistency to the assessment of the HTN related cardiac organ damage in children and adolescents.

In the PESESCAD-HTA study we found diastolic abnormalities even in prehypertensive adolescents without LVH which makes it clear the relevance of targeting diastolic alterations on individuals prone to be hypertensive likely in the short term (5)

In short, the issue of LVH in pediatric populations remains challenging. The solution will lie on in undertaking large multinational studies in an attempt to find out a more reliable and matching approach to determine the cardiac organ damage that HTN entails in children and adolescents.

Back in 1998. I was doing my Residence in General Medicine in Santa Clara. Villa Clara. Cuba, it was noon and I was set out to see my last patient. He was a 10-year-old boy brought to the clinic by his mother. He looked like a bit overweight and reported intermittent headache for more than two days. Upon taking medical history, the only positive complain was a frontal headache lasting about an hour with no other accompanying symptom.

At physical examination, there was nothing relevant, in my opinion, to point out. I must confess that I was somewhat bewildered about the cause of the headache. However, I explained to the mother that this pain could be the result of multiple causes while I was ordering a routine checkup. The patient was prescribed pain killers and I advised the mother that if something new raised to go the nearest health center. At the stage, the patient was ready to leave the office I came up with the idea to measure his blood pressure (BP) and to my surprise, he had 140 mmHg of systolic blood pressure with 95 mmHg of diastolic blood pressure. Undoubtedly, that was the cause of the persistent headache. I said to myself: “this patient is hypertensive and he is only 11 years old, what should I do?” Continue reading “The uncertain beginnings and the “why” of this blog.”

Nowadays, risk prediction is being focused as a key element in identifying risk factors for cardiovascular disease (CVD) since there are conditions such as arterial hypertension (HTN) for which the former statement can be fully justified,
taking into consideration its increasing prevalence in the early stages of life.
It is thus justifiable to give a wake-up call to the medical community to go to the root of the problem (childhood and adolescence) where the genesis of hypertension occurs. A management strategy should then be adopted to prevent the increased chances of developing hypertension in adulthood. This can also apply to other conditions such as familial hyperlipidemia, diabetes and obesity, involving the broad class of CVD.
The benefit will be far less when addressing these risk factors once damage is already established.
What do you think? We are looking forward to your comments. A “rate” always is highly appreciated.